What are the treatment options for migraine management?

Migraine Management: Treatment Options

For migraine management, a structured approach including both acute treatment and preventive therapy is recommended, with aspirin-acetaminophen-caffeine combination, NSAIDs, and triptans as first-line acute treatments, and topiramate, onabotulinumtoxinA, and CGRP monoclonal antibodies as evidence-based preventive options. 1, 2

Acute Treatment Options

First-Line Treatments

• NSAIDs and Combination Analgesics
  • Aspirin-acetaminophen-caffeine combination (strong recommendation) 1
  • Ibuprofen 400-800mg 1, 2
  • Naproxen sodium 1, 2
  • Diclofenac potassium 2
  • Acetylsalicylic acid 2

Second-Line Treatments

• Triptans
  • Sumatriptan (oral, subcutaneous, intranasal) 1, 2
  • Rizatriptan 1
  • Zolmitriptan 1
  • Naratriptan 1
  • Consider combining with NSAIDs for enhanced efficacy 2

Newer Options

• Gepants (weak recommendation)

  • Ubrogepant and rimegepant 1
  • Demonstrated moderately robust effects with number needed to treat of 13 for pain freedom at 2 hours 1

• Ditans

  • Lasmiditan (neither for nor against recommendation) 1
  • Shows benefit for pain freedom but has significant adverse effects including driving restrictions 1

Important Considerations

• Treat attacks early for better efficacy 1
• Consider route of administration based on nausea/vomiting presence 1
• Contraindications for triptans: coronary artery disease, stroke, TIA, hemiplegic or basilar migraine, peripheral vascular disease, uncontrolled hypertension 2

Preventive Treatment Options

First-Line Preventive Medications

• For Chronic Migraine (≥15 headache days/month)

  • OnabotulinumtoxinA (Botox) - first choice 2
  • Topiramate (100 mg/day) - reduces migraine days by approximately 3.5 days per month 1, 2
  • CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) - for patients with multiple failed preventive treatments 1, 3

• For Episodic Migraine

  • Beta-blockers: Propranolol (80-240 mg/day), Timolol (20-30 mg/day) 2, 4, 5
  • Anticonvulsants: Divalproex sodium (500-1500 mg/day), Sodium valproate (800-1500 mg/day), Topiramate (100 mg/day) 2, 4, 5
  • Antidepressants: Amitriptyline (30-150 mg/day) 2, 4, 5
  • CGRP monoclonal antibodies - for high-frequency episodic migraines 2
  • Angiotensin receptor blockers: Candesartan 2, 5

Second-Line Options

• Venlafaxine 6
• Gabapentin 6, 5
• Naproxen 6

Nutraceuticals with Evidence

• Magnesium (400-600mg daily) - most evidence-supported supplement 2, 6, 5
• Riboflavin (vitamin B2) 2, 6, 5
• Coenzyme Q10 2, 4
• Butterbur root 6

Lifestyle Modifications and Non-Pharmacological Approaches

Trigger Management

• Maintain headache diary to identify triggers 2
• Address modifiable risk factors: obesity, medication overuse, caffeine use, sleep disturbances 1, 2, 7

Behavioral Interventions

• Regular aerobic exercise 2, 7
• Consistent sleep schedule 2, 7
• Adequate hydration and regular meals 2, 7
• Stress management techniques 2, 7
• Biofeedback 4
• Cognitive-behavioral therapy 4
• Relaxation therapy 4

Management of Medication Overuse Headache (MOH)

• Educate patients about risk of MOH with frequent use of acute medications 1
• Withdraw overused medication - abrupt withdrawal preferred except for opioids 1
• Limit acute medications to <10-15 days/month 2

Special Considerations

Comorbidity Management

• Select preventive medications based on comorbidities 1, 2
  • Topiramate for patients with obesity (associated with weight loss) 1
  • Amitriptyline for patients with depression or sleep disturbances 1
  • Avoid amitriptyline in patients with heart failure or glaucoma 2

Monitoring and Follow-up

• Evaluate treatment response after 2-3 months of optimized preventive therapy 2
• Treatment failure criteria: <50% reduction in monthly migraine days, no significant improvement in headache-related disability, or intolerable side effects 2
• Consider referral to specialist for refractory cases 2

Red Flags Requiring Further Evaluation

• Sudden severe "thunderclap" headache
• Headache with fever, stiff neck, confusion
• New headache with neurological symptoms
• Headache worsened with Valsalva maneuver or that awakens from sleep 2

By implementing this comprehensive approach to migraine management, patients can experience significant reductions in migraine frequency, severity, and associated disability, ultimately improving their quality of life.