What is the evidence-based practice (EBP) for managing migraines?

Evidence-Based Practice for Migraine Management

The most effective evidence-based approach for managing migraines includes a stratified care model using NSAIDs or triptans for acute attacks and beta blockers, topiramate, or candesartan for prevention in patients with frequent or disabling headaches. 1

Acute Treatment of Migraine

First-Line Options

• For mild to moderate attacks:

  • Aspirin-acetaminophen-caffeine combination 1
  • NSAIDs (ibuprofen, naproxen) with antiemetics if needed 1

• For moderate to severe attacks:

  • Triptans (sumatriptan, rizatriptan, etc.) 1, 2
    • Sumatriptan 50mg or 100mg shows significant efficacy with NNT of 4.0 for headache relief at 2 hours 2, 3
    • Subcutaneous administration provides more rapid relief than oral route 4

Second-Line Options

• Gepants (ubrogepant, rimegepant) for patients who don't respond to or cannot tolerate triptans 1
• Ditans (lasmiditan) as alternative when triptans are contraindicated 1

Important Considerations

• Early treatment during mild pain phase significantly improves outcomes 2, 3
• Limit acute therapy to no more than twice weekly to prevent medication-overuse headache 1
• Consider rescue medication (e.g., antiemetics) for breakthrough symptoms 1
• Avoid opioids due to risk of dependence and medication-overuse headache 1

Preventive Treatment of Migraine

Indications for Prevention

1. Two or more attacks per month with disability lasting ≥3 days/month
2. Contraindication to or failure of acute treatments
3. Use of acute medication more than twice weekly
4. Presence of uncommon migraine conditions (hemiplegic migraine, migraine with prolonged aura) 1

First-Line Preventive Options

• Beta blockers (atenolol, bisoprolol, metoprolol, propranolol)
• Topiramate
• Candesartan 1

Second-Line Preventive Options

• Flunarizine
• Amitriptyline
• Sodium valproate (in men only) 1

Third-Line Options

• CGRP monoclonal antibodies for chronic migraine or when other preventives fail 1

Non-Pharmacological Approaches

Evidence-Based Options

• Physical therapy and rehabilitation interventions 1
• Aerobic exercise or progressive strength training (2-3 times weekly for 30-60 minutes) 1
• Relaxation training and biofeedback combined with relaxation training 1

Limited Evidence Options

• Acupuncture (evidence is mixed) 1
• Cognitive-behavioral therapy 1

Special Populations

Older Adults

• Consider cardiovascular comorbidities when selecting treatments
• Monitor blood pressure in older patients using triptans 1

Children and Adolescents

• Ibuprofen is recommended first-line at age-appropriate dosing
• Bed rest alone may be sufficient for short-duration attacks 1

When to Refer to Neurology

• Presence of "red flag" symptoms suggesting secondary headache
• Failure to respond to appropriate first-line treatments
• Suspected cluster headache
• Chronic migraine not responding to standard preventive treatments 5

Common Pitfalls to Avoid

• Using acute medications too frequently (>2 days/week), which can lead to medication-overuse headache 1
• Delaying preventive therapy in patients with frequent or disabling attacks 1
• Missing red flags that suggest secondary headache requiring urgent evaluation 5
• Failing to address comorbidities like anxiety, depression, and sleep disturbances that can worsen migraine 1

The evidence strongly supports a stratified approach to migraine management, with treatment selection based on attack severity, frequency, and individual patient factors. Early intervention for acute attacks and appropriate preventive therapy for frequent migraines are key to reducing disability and improving quality of life.