What are the recommended treatments for migraine management?

Migraine Management: Evidence-Based Treatment Approach

NSAIDs should be used as first-line treatment for acute migraine attacks, with triptans considered if response is inadequate, while preventive therapy should be initiated for patients experiencing 4 or more migraine days per month or significant disability despite appropriate acute treatment. 1

Acute Treatment

First-Line Options

• NSAIDs:
  • Ibuprofen 400-800mg or naproxen 500-550mg administered as early as possible during attack 1
  • Provide effective relief with lower cost and fewer side effects than other options
  • Should be limited to ≤10 days per month to prevent medication overuse headache 1

Second-Line Options (if NSAIDs inadequate)

• Triptans:
  • Sumatriptan, rizatriptan, zolmitriptan, naratriptan are effective options
  • Clinical trials show 50-62% of patients achieve headache response within 2 hours with sumatriptan 50-100mg compared to 17-27% with placebo 2
  • Rizatriptan shows similar efficacy with 33% of patients achieving pain freedom at 2 hours 3
  • Non-oral formulations with antiemetics should be considered for patients with severe nausea/vomiting 1

Medications to Avoid

• Acetaminophen alone: Limited efficacy evidence 1
• Opioids and butalbital: Can lead to medication overuse headache and dependency 1

Preventive Treatment

Indications for Prevention

Preventive therapy should be considered for patients with:

• 4 or more migraine days per month
• Severe debilitating headaches despite adequate acute treatment
• Inability to tolerate or contraindications to acute treatments
• Using acute treatments more frequently than recommended
• Significant disability despite appropriate acute treatment 1

First-Line Preventive Medications

1. Beta-blockers:

   • Propranolol (80-240 mg/day)
   • Timolol (20-30 mg/day) 1

2. Anticonvulsants:

   • Topiramate (evidence supports effectiveness in both episodic and chronic migraine) 4, 1
   • Divalproex sodium (500-1500 mg/day) 1

3. Antidepressants:

   • Amitriptyline (30-150 mg/day) - particularly beneficial for patients with depression or sleep disturbances 4, 1

4. CGRP Monoclonal Antibodies:

   • Erenumab, fremanezumab, galcanezumab
   • Proven beneficial for patients in whom at least two other preventive medications have failed 4
   • Generally limited by regulatory restrictions to patients after failure of other preventives 4

5. For Chronic Migraine:

   • OnabotulinumtoxinA - effective for chronic migraine after other preventives have failed 4

Practical Approach to Preventive Treatment

• Start at low dose and gradually increase until desired outcomes are achieved 1
• Allow 2-3 months to assess efficacy before determining treatment failure 1
• Consider earlier switch if adverse effects occur 1
• Use headache diaries to track frequency, severity, and medication use 1

Non-Pharmacological Approaches

Lifestyle Modifications

• Maintain regular sleep schedule, meal times, and hydration 1
• Regular aerobic exercise (30 minutes of moderate activity most days) 1
• Stress management techniques (deep breathing, progressive muscle relaxation, meditation) 1
• Identify and avoid personal migraine triggers 5

Supplements

• Magnesium (400-600mg daily)
• Riboflavin/Vitamin B2 (400mg daily)
• Coenzyme Q10 1, 6

Management of Chronic Migraine

Chronic migraine (≥15 headache days per month for >3 months, with ≥8 days having migraine features) requires special consideration:

1. Rule out medication overuse headache (MOH) 4

   • Educate patients about risk of MOH with frequent use of acute medications
   • Manage established MOH by withdrawal of overused medication (abrupt withdrawal preferred, except for opioids)

2. Preventive medications with evidence for chronic migraine:

   • Topiramate (first choice due to lower cost)
   • OnabotulinumtoxinA
   • CGRP monoclonal antibodies 4

3. Refer to specialist care when chronic migraine is established 4

Recognizing and Managing Comorbidities

• Identify and address common comorbidities: anxiety, depression, sleep disturbances, obesity, chronic pain conditions 4
• Tailor treatment based on comorbidities:
  • Topiramate preferred for patients with obesity (associated with weight loss)
  • Amitriptyline beneficial for depression or sleep disturbances 4

Red Flags Requiring Further Evaluation

Immediate medical attention needed for:

• Sudden, severe "thunderclap" headache
• Headache with fever, stiff neck, confusion
• Headache after head injury
• New headache with neurological symptoms
• Headache worsened with Valsalva maneuver or that awakens from sleep 1

Treatment Goals and Monitoring

• Primary goals: rapidly and consistently treat attacks, restore functional ability, minimize need for rescue medications, minimize adverse effects 1
• Use headache diaries to track frequency, severity, and medication use
• Assess response to preventive treatment after 2-3 months 1
• Consider referral to neurologist if headaches remain refractory to multiple treatment options 1