What are the treatment options for migraines?

Treatment Options for Migraines

The mainstay of migraine management includes both prophylactic medications and acute treatments, with beta-blockers (propranolol 80-240 mg/day, timolol 20-30 mg/day), antiseizure medications (topiramate 100 mg/day), and tricyclic antidepressants (amitriptyline 30-150 mg/day) being first-line preventive options, while simple analgesics and triptans are first-line for acute attacks. 1, 2

Prophylactic Treatment Options

When to Initiate Preventive Therapy

• ≥4 headaches per month
• ≥8 headache days per month
• Debilitating headaches
• Medication-overuse headaches 1

First-Line Prophylactic Medications

1. Beta-blockers

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

2. Antiseizure medications

   • Topiramate (100 mg/day)
   • Divalproex sodium (500-1500 mg/day) 1

3. Tricyclic antidepressants

   • Amitriptyline (30-150 mg/day) - start at 10-25mg at bedtime, increase by 10-25mg every 1-2 weeks 1

Second-Line Prophylactic Options

• Angiotensin receptor blockers (candesartan 8-32 mg daily)
• SNRIs (venlafaxine 75-150 mg daily)
• Calcium channel blockers (flunarizine) 1

Supplemental Therapies

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

Acute Treatment Options

Mild to Moderate Attacks

1. Simple analgesics (first-line)
   • Acetaminophen 1000 mg
   • NSAIDs:
     • Ibuprofen 400-800 mg
     • Naproxen 500-1000 mg
     • Aspirin 1000 mg 2, 3, 4

Moderate to Severe Attacks

1. Triptans (first-line)

   • Sumatriptan (oral, nasal, injectable)
   • Important safety considerations:
     • Contraindicated in coronary artery disease, Prinzmetal's variant angina, uncontrolled hypertension, and Wolff-Parkinson-White syndrome 5, 6
     • Risk of serotonin syndrome when combined with SSRIs/SNRIs 5, 6
     • Should not be used within 24 hours of ergot-containing medications 5

2. Antiemetics (second-line)

   • Metoclopramide 10-20 mg
   • Domperidone 20 mg 4, 7

3. Ergot alkaloids (second-line)

   • Dihydroergotamine 2, 4

Non-Pharmacological Interventions

• Relaxation training
• Thermal biofeedback combined with relaxation training
• Cognitive behavioral therapy
• Regular aerobic exercise
• Maintaining regular sleep schedule
• Regular meals and adequate hydration 1

Treatment Monitoring and Goals

• Target goal: 50% reduction in attack frequency
• Allow 6-8 weeks at therapeutic dose to evaluate efficacy
• If first preventive medication fails after adequate trial, switch to another first-line agent 1

Special Considerations

Medication Overuse Headache Prevention

• Limit use of simple analgesics to fewer than 15 days/month
• Limit triptans to fewer than 10 days/month 1

Pregnancy Considerations

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

Triptan Safety Warnings

• Monitor for signs of coronary vasospasm, especially in patients with risk factors for CAD
• Watch for cerebrovascular events (stroke, hemorrhage)
• Be alert for potential serotonin syndrome when combining with SSRIs/SNRIs 5, 6

By following this structured approach to migraine management, focusing on both preventive and acute treatments, most patients can achieve significant reduction in migraine frequency and severity, improving their quality of life and reducing disability.