What is the treatment for persistent migraine?

Treatment for Persistent Migraine

The most effective treatment for persistent migraine includes preventive medications such as amitriptyline (30-150 mg/day), propranolol (80-240 mg/day), topiramate (100 mg/day), or candesartan (8-32 mg daily), combined with acute treatment using triptans like sumatriptan for breakthrough attacks. 1

First-Line Preventive Treatments

Pharmacological Options

• Tricyclic Antidepressants

  • Amitriptyline: Start at 10-25mg at bedtime, increase by 10-25mg every 1-2 weeks to target dose of 30-150mg 1
  • Nortriptyline: Alternative for those who cannot tolerate amitriptyline; start at 10mg at bedtime, increase by 10mg every 5-7 days to maximum of 40mg 1

• Beta-Blockers

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

• Anticonvulsants

  • Topiramate: 100 mg/day (caution: teratogenic) 1
  • Divalproex sodium: 500-1500 mg/day (caution: teratogenic) 1
  • Sodium valproate: 800-1500 mg/day 1

• Angiotensin Receptor Blockers

  • Candesartan: 8-32 mg daily (beneficial for patients with hypertension) 1

Evaluation of Preventive Therapy

• Assess response after 6-8 weeks of treatment 1
• Target goal: 50% reduction in headache frequency 1
• Monitor for side effects specific to each medication class 1

Acute Treatment for Breakthrough Attacks

• Triptans (for moderate to severe attacks)

  • Sumatriptan: Available evidence shows 50-100mg doses provide significantly better headache relief at 2 and 4 hours compared to placebo 2
  • Clinical trials demonstrated 50-62% of patients achieved headache response within 2 hours and 68-79% within 4 hours using 50-100mg doses 2

• Simple Analgesics (for mild to moderate attacks)

  • NSAIDs
  • Acetaminophen

• Important Caution: Limit use of simple analgesics to fewer than 15 days/month and triptans to fewer than 10 days/month to prevent medication overuse headache 1

Non-Pharmacological Approaches

Supplements with Evidence

• Magnesium: 400-600mg daily 1
• Riboflavin (Vitamin B2): 400mg daily (may take 2-3 months for full benefit) 1
• Coenzyme Q10 1

Behavioral Interventions

• Cognitive behavioral therapy 1
• Relaxation training 1
• Mindfulness-based treatment 1
• Regular aerobic exercise 1

Lifestyle Modifications

• Maintain regular sleep schedule 1
• Eat regular meals 1
• Practice stress management techniques 1
• Ensure adequate hydration 1
• Identify and avoid personal migraine triggers 1

Special Considerations

Women of Childbearing Age

• Avoid topiramate and valproate due to teratogenic effects 1
• Women with migraine with aura should avoid combined hormonal contraceptives with estrogens due to increased stroke risk 1

Patients with Comorbidities

• Insomnia: Consider amitriptyline or nortriptyline for their sedating properties 1
• Obesity: Consider topiramate which may assist with weight loss 1
• Diabetes: Monitor blood glucose more frequently when initiating preventive medications 1
• Renal impairment: Use magnesium with caution 1

Treatment Algorithm

1. Start with preventive therapy if:

   • Headaches occur ≥4 days per month
   • Significant disability despite acute treatment
   • Contraindication to or overuse of acute treatments

2. Choose preventive medication based on:

   • Comorbidities (e.g., depression, hypertension, insomnia)
   • Contraindications
   • Side effect profile

3. Provide acute treatment for breakthrough attacks:

   • Sumatriptan 50-100mg for moderate to severe attacks
   • Simple analgesics for mild attacks

4. Implement lifestyle modifications and behavioral interventions concurrently

5. Evaluate effectiveness after 6-8 weeks:

   • If ≥50% reduction in headache frequency, continue treatment
   • If inadequate response, increase dose or switch to alternative medication