What are the steps to manage migraine?

From the Guidelines

Managing migraines effectively requires a comprehensive approach combining preventive measures and acute treatment strategies, starting with identifying and avoiding personal migraine triggers and establishing a consistent daily routine. The steps to manage migraine include:

• Identifying and avoiding personal migraine triggers, which commonly include stress, certain foods, irregular sleep patterns, and environmental factors like bright lights or strong smells 1
• Establishing a consistent daily routine with regular sleep, meals, and exercise
• For acute migraine attacks, taking medication as early as possible, with options including over-the-counter pain relievers like ibuprofen (400-600mg) or aspirin (650-1000mg), or prescription medications such as triptans (sumatriptan 50-100mg) or gepants (ubrogepant 50-100mg) 1
• Resting in a dark, quiet room and applying cold or hot compresses to the head or neck
• For frequent migraines (more than 4 monthly), considering preventive medications, including beta-blockers (propranolol 80-240mg daily), anticonvulsants (topiramate 25-100mg daily), certain antidepressants, or CGRP antagonists (erenumab 70-140mg monthly injection) 1
• Keeping a migraine diary to track triggers, symptoms, and treatment effectiveness
• Considering non-medication approaches like biofeedback, cognitive behavioral therapy, acupuncture, and stress management techniques to complement medical treatment 1 The most recent and highest quality study recommends offering acute medication to everyone who experiences migraine attacks, advising use of acute medications early in the headache phase, and considering preventive therapy for frequent migraines 1.

From the FDA Drug Label

The estimated probability of achieving an initial headache response within 2 hours following treatment in pooled Studies 1,2,3, and 4 is depicted in Figure 1 Figure 1 shows the Kaplan-Meier plot of the probability over time of obtaining headache response (no or mild pain) following treatment with rizatriptan benzoate or placebo For patients with migraine-associated photophobia, phonophobia, and nausea at baseline, there was a decreased incidence of these symptoms following administration of rizatriptan benzoate compared to placebo Two to 24 hours following the initial dose of study treatment, patients were allowed to use additional treatment for pain response in the form of a second dose of study treatment or other medication.

The steps to manage migraine are:

• Assess the patient's symptoms: Evaluate the patient's headache response and associated symptoms such as photophobia, phonophobia, and nausea.
• Administer rizatriptan benzoate: Give the patient a dose of rizatriptan benzoate, and assess the response within 2 hours.
• Allow additional treatment: If the patient's symptoms persist, allow the use of additional treatment, such as a second dose of rizatriptan benzoate or other medication, 2 to 24 hours after the initial dose.
• Monitor for adverse reactions: Watch for potential adverse reactions, such as chest, throat, neck, and/or jaw pain/tightness/pressure, cerebrovascular events, and serotonin syndrome.
• Consider detoxification: If the patient is experiencing medication overuse headache, consider detoxification, including withdrawal of the overused drugs and treatment of withdrawal symptoms.

2

From the Research

Steps to Manage Migraine

To manage migraine effectively, the following steps can be taken:

• Identify and manage triggers: This includes environmental factors, sleep pattern changes, diet, physical activity, stress and anxiety, some medications, and hormonal changes 3
• Learn coping skills: Patients should learn skills to cope with trigger factors that are difficult to avoid 3
• Maintain a healthy lifestyle: This includes weight control, management of migraine comorbidities, lifestyle modification, and behavioral treatment 3, 4
• Keep a headache diary: This can help improve patients' knowledge about the disease and identify patterns and triggers 3
• Consider non-pharmacological approaches: These include neuromodulation techniques, dietary supplements such as riboflavin, coenzyme Q10, and magnesium, and acupuncture 3
• Use pharmacological treatments: These include antiemetics, analgesics, ergotamine, and triptans for acute attacks, and beta-blockers, calcium channel blockers, and antiepileptic drugs for prophylaxis 5, 6, 7

Non-Pharmacological Management

Non-pharmacological management of migraine includes:

• Lifestyle advice: Avoiding situations that trigger attacks, maintaining a healthy diet, and getting adequate sleep 6, 4
• Behavioral treatment: This includes biofeedback and stress management techniques 3
• Patient education: Improving patients' knowledge about the disease and its management 3

Pharmacological Management

Pharmacological management of migraine includes:

• Acute treatment: Antiemetics, analgesics, ergotamine, and triptans 5, 6, 7
• Prophylaxis: Beta-blockers, calcium channel blockers, and antiepileptic drugs 5, 6, 7
• Combination therapy: Combining pharmacological and non-pharmacological approaches can be more effective than using each separately 3