From the Guidelines
Migraine management should prioritize a combination of acute treatments, such as triptans and NSAIDs, and preventive strategies, including lifestyle modifications and pharmacologic treatments, to reduce frequency and severity, as recommended by the most recent guidelines from the American College of Physicians 1.
Acute Treatment
For acute treatment, first-line medications include triptans, such as sumatriptan, and NSAIDs, like ibuprofen or naproxen, which should be taken early in an attack for maximum effectiveness. Combination therapy with a triptan plus an NSAID often works better than either alone 1. Newer options include gepants and ditans for those who don't respond to or can't tolerate triptans.
- Consider using a nonoral triptan and an antiemetic in people having severe nausea or vomiting.
- Counsel patients to begin treatment of migraine headache as soon as possible after its onset.
Preventive Treatment
For prevention, first-line options include beta-blockers, anticonvulsants, and certain antidepressants, such as propranolol, topiramate, and amitriptyline. CGRP monoclonal antibodies given monthly or quarterly are effective newer preventives with fewer side effects.
- Patients should be evaluated for the use of preventive therapy if they experience two or more attacks per month that produce disability lasting 3 or more days per month.
- Consider the addition of preventive medications if episodic migraine occurs frequently or treatment does not provide an adequate response.
Lifestyle Modifications
Lifestyle modifications, including staying well hydrated, maintaining regular meals, securing sufficient and consistent sleep, engaging in regular physical activity, managing stress, and pursuing weight loss for those who are overweight or obese, are crucial in migraine management.
- Explore modifiable migraine triggers or contributing factors during a detailed history.
- Highlight the importance of lifestyle modifications with patients.
From the FDA Drug Label
1 INDICATIONS AND USAGE AIMOVIG is indicated for the preventive treatment of migraine in adults.
CLINICAL STUDIES The efficacy of sumatriptan tablets in the acute treatment of migraine headaches was demonstrated in 3, randomized, double-blind, placebo-controlled trials.
The recommended treatments for migraine management include:
- Preventive treatment: erenumab (SQ) is indicated for the preventive treatment of migraine in adults 2.
- Acute treatment: sumatriptan (PO) is effective in the acute treatment of migraine headaches, with doses of 25,50, and 100 mg compared with placebo showing a significantly greater percentage of patients achieving headache response 2 and 4 hours after treatment 3.
From the Research
Migraine Management Overview
Migraine is a common condition affecting a significant portion of the population, with approximately 18% of women and 6% of men in the United States experiencing it 4. The primary goals of managing migraine are to prevent attacks from occurring and to effectively and rapidly end them when they do occur.
Recommended Treatments
The recommended treatments for migraine management can be divided into preventive and acute treatments. Preventive measures include:
- Lifestyle changes, such as avoiding migraine triggers and maintaining regular sleep, eating, and work habits 4, 5, 6
- Drug therapy, including beta-blockers, calcium channel blockers, tricyclic antidepressants, and anticonvulsants 4, 5
- Non-pharmacological approaches, such as weight control, management of migraine comorbidities, lifestyle modification, behavioral treatment, and biofeedback 6
Acute treatments include:
- Over-the-counter analgesics 4, 7
- Prescription drugs, such as 5-hydroxytryptamine(1B/1D)-receptor agonists (triptans) 4, 7
- Non-specific treatments, such as general analgesics (aspirin or non-steroidal anti-inflammatory drugs) 7
Individualized Treatment Plans
It is essential to develop an individualized treatment plan based on the patient's needs and preferences, taking into account the frequency of migraine attacks, extent of migraine-associated disability, and patient preferences 8, 5. The plan should aim to reduce attack frequency, intensity, and duration, minimize headache-related disability, and improve health-related quality of life.
Emerging Therapies
New therapies, such as erenumab, a calcitonin gene-related peptide (CGRP) receptor monoclonal antibody, have received approval for the prevention of migraine 5. Additionally, non-pharmacological approaches, such as neuromodulation techniques, dietary supplements (riboflavin, coenzyme Q10, and magnesium), and acupuncture, can be helpful in managing migraine 6.