What is the recommended approach for managing migraines?

Comprehensive Management Approach for Migraine

The most effective approach for managing migraines involves a stepped care strategy with NSAIDs as first-line acute treatment, triptans as second-line, and preventive therapy for patients with frequent or disabling attacks, along with lifestyle modifications to identify and avoid triggers. 1

Diagnosis and Initial Assessment

• Suspect migraine when patients present with:

  • Recurrent moderate to severe headaches
  • Visual aura symptoms (fortification spectra)
  • Family history of migraine
  • Onset around puberty
  • Associated symptoms: photophobia, phonophobia, nausea, vomiting

• Key diagnostic criteria for migraine without aura:

  • Headaches lasting 4-72 hours
  • At least two of: unilateral location, pulsating quality, moderate/severe intensity, aggravation by physical activity
  • At least one of: nausea/vomiting, photophobia and phonophobia

Acute Treatment Algorithm

First-Line Treatment

• NSAIDs with proven efficacy:
  • Acetylsalicylic acid
  • Ibuprofen
  • Diclofenac potassium
  • Add antiemetic if necessary for nausea/vomiting
  • Paracetamol only if NSAIDs are contraindicated

Second-Line Treatment (if NSAIDs fail after 3 consecutive attacks)

• Triptans (most effective when taken early while headache is mild)
  • Important safety considerations for triptans 2, 3:
    • Contraindicated in patients with coronary artery disease, Prinzmetal's angina
    • Contraindicated in patients with history of stroke or TIA
    • Contraindicated in uncontrolled hypertension
    • Monitor for serotonin syndrome when combined with SSRIs/SNRIs
    • May cause non-cardiac chest/throat/neck tightness
  • If one triptan fails, try another (they have different efficacy profiles)
  • For rapid onset or severe attacks: consider sumatriptan subcutaneous injection

Third-Line Treatment (if all triptans fail)

• Newer options (limited availability):
  • Ditans (lasmiditan)
  • Gepants (ubrogepant, rimegepant)

Preventive Treatment

Initiate preventive therapy when:

• ≥2 disabling headache days per month despite optimized acute treatment
• Attacks significantly impact quality of life despite acute treatment
• Risk of medication overuse headache

First-Line Preventive Options

• Beta-blockers (metoprolol, propranolol)
• Topiramate
• Candesartan

Second-Line Preventive Options

• Flunarizine
• Amitriptyline
• Sodium valproate (contraindicated in women of childbearing potential)

Third-Line Preventive Options

• CGRP monoclonal antibodies

Lifestyle Modifications and Non-Pharmacological Approaches

• Identify and manage trigger factors:

  • Sleep disturbances (maintain regular sleep schedule)
  • Stress (implement stress management techniques)
  • Dietary factors (alcohol, fasting, certain foods)
  • Hormonal changes (consider perimenstrual prevention in women)
  • Environmental factors (weather changes, bright lights)

• Implement healthy lifestyle habits:

  • Regular physical activity
  • Weight management
  • Regular meals to avoid hypoglycemia
  • Adequate hydration

• Consider complementary approaches:

  • Biofeedback
  • Neuromodulation devices
  • Acupuncture

Special Considerations

For Women with Menstrual Migraine

• Consider perimenstrual prevention with long-acting NSAIDs or triptans starting 2 days before expected menstruation

For Pregnant/Breastfeeding Women

• Use paracetamol for acute treatment
• Avoid preventive medications when possible

For Children and Adolescents

• Ibuprofen is first-line acute treatment
• Bed rest alone may be sufficient for short attacks

Monitoring and Follow-up

• Use headache calendars to track:

  • Attack frequency, duration, and intensity
  • Medication use and effectiveness
  • Potential triggers

• Evaluate treatment response after 2-3 months and regularly thereafter

• Watch for medication overuse headache (use of acute medications ≥10 days/month)

• Consider specialist referral for:

  • Treatment-resistant cases
  • Atypical presentations
  • Chronic migraine (≥15 headache days/month for >3 months)

Common Pitfalls to Avoid

• Failing to recognize medication overuse headache
• Using triptans during aura phase (no evidence of benefit)
• Overlooking comorbidities that may affect treatment choice
• Neglecting to educate patients about proper medication timing and use
• Missing secondary headache disorders in patients with late-onset migraine

This comprehensive approach addresses both acute treatment and prevention while emphasizing the importance of lifestyle modifications and regular monitoring to optimize migraine management and improve quality of life.