What is the treatment protocol for migraines in a primary care office?

From the Guidelines

The treatment protocol for migraines in a primary care office involves a stepwise approach combining acute and preventive strategies, with first-line options including NSAIDs, triptans, and lifestyle modifications, as well as preventive medications such as beta blockers, topiramate, and CGRP monoclonal antibodies, as recommended by the most recent guidelines 1.

Acute Treatment

For acute treatment, the following options are recommended:

• NSAIDs such as ibuprofen (400-600mg) or naproxen (500-550mg) at the first sign of headache
• Triptans, with sumatriptan (50-100mg orally, 6mg subcutaneously, or 20mg intranasally) being commonly prescribed
• Antiemetics like metoclopramide (10mg) or prochlorperazine (10mg) for patients with severe nausea

Preventive Therapy

Preventive therapy should be considered when migraines occur more than 4 days per month, significantly impact quality of life, or when acute treatments are ineffective. First-line preventive medications include:

• Beta blockers such as propranolol (80-240mg daily)
• Topiramate (50-200mg daily)
• CGRP monoclonal antibodies, such as erenumab, fremanezumab, and galcanezumab, which have been shown to be effective in reducing migraine frequency and severity 1

Lifestyle Modifications

Lifestyle modifications are essential components of migraine management, including:

• Regular sleep patterns
• Stress management
• Regular meals
• Adequate hydration
• Trigger avoidance

Patient Education

Patient education about medication overuse headache is crucial, as using acute medications more than 10-15 days per month can worsen headaches. Follow-up should occur every 4-6 weeks initially to assess treatment efficacy and adjust as needed, with the goal of reducing headache frequency by at least 50% 1.

From the FDA Drug Label

The recommended dose of sumatriptan tablets is 25 mg, 50 mg, or 100 mg. Doses of 50 mg and 100 mg may provide a greater effect than the 25 mg dose, but doses of 100 mg may not provide a greater effect than the 50 mg dose. If the migraine has not resolved by 2 hours after taking sumatriptan tablets, or returns after a transient improvement, a second dose may be administered at least 2 hours after the first dose. The maximum daily dose is 200 mg in a 24-hour period

The treatment protocol for migraines in a primary care office using sumatriptan tablets is as follows:

• Initial Dose: 25 mg, 50 mg, or 100 mg
• Repeat Dose: If the migraine has not resolved by 2 hours after taking sumatriptan tablets, or returns after a transient improvement, a second dose may be administered at least 2 hours after the first dose
• Maximum Daily Dose: 200 mg in a 24-hour period 2 2

From the Research

Treatment Protocol for Migraines in a Primary Care Office

The treatment protocol for migraines in a primary care office involves a step-by-step approach to manage the condition effectively. The following are the key components of the protocol:

• Assessment and Diagnosis: Accurately diagnose migraine and assess the frequency, intensity, and duration of attacks, as well as the presence of any aura or other symptoms 3.
• Acute Treatment: Use nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line treatment for mild to moderate migraine attacks, and triptans for moderate to severe attacks or when NSAIDs are ineffective 3, 4, 5.
• Treatment Strategies: Consider the following treatment strategies:
  • Take medication early in an attack, when pain is still mild, for better efficacy 6, 7.
  • Use a stratified treatment approach, where patients with less frequent episodic migraine use acute agents at the earliest signs of headache, and those with frequent headache (>10 days per month) limit acute treatments to only the most disabling episodes to avoid medication overuse 3.
  • Consider rescue or back-up therapy for patients who do not respond to initial treatment 3.
• Medication Options: The following medications have evidence supporting their effectiveness in the treatment of migraine:
  • Acetaminophen and NSAIDs for mild to moderate migraines 5.
  • Triptans for moderate to severe migraines 4, 6, 7, 5.
  • Antiemetics and ergot alkaloids as second- or third-line therapy for select patients or for those with refractory migraine 5.
• Individualized Treatment: Tailor treatment to the individual patient based on the pattern and severity of attacks, as well as the presence of any comorbidities or contraindications to certain medications 5.
• Follow-up and Monitoring: Regularly follow up with patients to monitor the effectiveness of treatment, adjust the treatment plan as needed, and provide education on migraine management and prevention 3.