What are the current guidelines for managing migraines?

Current Guidelines for Managing Migraines

NSAIDs are the first-line treatment for acute migraine attacks, followed by triptans for those who don't respond, while preventive therapy should be considered for patients with frequent attacks (≥2 per month) or significant disability. 1

Acute Treatment Strategy

First-Line Treatment

• NSAIDs are recommended as first-line treatment for most patients with migraine 2, 1
  • Ibuprofen: 400-800 mg every 6 hours (maximum 2.4g daily)
  • Naproxen sodium: 275-550 mg every 2-6 hours (maximum 1.5g daily)
  • Aspirin: 650-1000 mg every 4-6 hours (maximum 4g daily)
  • Acetaminophen-aspirin-caffeine combination
• Acetaminophen alone is less effective than NSAIDs and should only be used in patients who cannot tolerate NSAIDs 1

Second-Line Treatment

• Triptans should be used when NSAIDs are ineffective 2, 1
  • Options include sumatriptan, rizatriptan, naratriptan, zolmitriptan, eletriptan, and frovatriptan
  • Sumatriptan: 50 mg orally or 6 mg subcutaneously for severe attacks or significant nausea/vomiting
  • Rizatriptan: 10 mg orally
  • A combination of sumatriptan and naproxen is strongly recommended for enhanced efficacy 1

Important Considerations for Acute Treatment

• Triptans are most effective when taken early in an attack while pain is still mild 2
• Triptans should not be used during the aura phase 2
• Triptans are contraindicated in patients with: 1, 3
  • Uncontrolled hypertension
  • Coronary artery disease or vasospasm
  • Wolff-Parkinson-White syndrome
  • History of stroke or TIA
  • Hemiplegic or basilar migraine
  • Peripheral vascular disease
  • Concurrent use of MAO inhibitors
• For patients with nausea/vomiting, use non-oral routes of administration and consider antiemetic medications 2
• Limit acute medications to prevent medication overuse headache: 1
  • NSAIDs: no more than 15 days per month
  • Triptans: no more than 9 days per month
  • Combination analgesics: no more than 10 days per month

Preventive Treatment

Indications for Preventive Therapy

Preventive treatment should be considered when: 2, 1

• Migraine attacks occur ≥2 times per month with disability lasting ≥3 days
• Acute treatments are ineffective, contraindicated, or overused (>2 days/week)
• Uncommon migraine conditions are present (prolonged aura, migrainous infarction, hemiplegic migraine)
• Patient preference and treatment costs

First-Line Preventive Medications

• Beta-blockers: 2, 1
  • Propranolol: 80-240 mg per day
  • Timolol: 20-30 mg per day
  • Metoprolol: 50-200 mg per day
• Anticonvulsants: 1
  • Topiramate: 25-100 mg per day
  • Divalproex sodium: 500-1,500 mg per day
  • Sodium valproate: 800-1,500 mg per day
• Antidepressants:
  • Amitriptyline: 30-150 mg per day 2

Additional Preventive Options

• OnabotulinumtoxinA (Botox) for chronic migraine (≥15 headache days/month) 4
• Magnesium or riboflavin supplementation as adjunctive treatments 1
• CGRP antagonists (not mentioned in the provided evidence but are newer options)

Non-Pharmacological Approaches

• Lifestyle modifications: 2, 1
  • Maintain regular sleep schedule
  • Eat regular meals
  • Engage in moderate aerobic exercise
  • Manage stress
• Consider predisposing and trigger factors, though their role may be limited 2
• Track headache patterns using a diary to monitor frequency, severity, medication use, and potential triggers 2, 1

Follow-up and Monitoring

• Schedule follow-up in 4-6 weeks to assess treatment effectiveness 1
• Use headache diary to track frequency, severity, and medication use 1
• Consider referral to a neurologist or headache specialist if no improvement after trials of 2-3 preventive medications 1
• Monitor for medication overuse headache, which can develop with frequent use of acute treatments 2, 1

Common Pitfalls to Avoid

• Using acetaminophen alone as first-line treatment (less effective than NSAIDs) 1
• Using triptans in patients with cardiovascular contraindications 3
• Overusing acute medications, leading to medication overuse headache 2, 1
• Failing to consider preventive therapy in patients with frequent attacks 2, 1
• Overemphasizing trigger factors, which may have limited importance except for menstruation in some women 2
• Using opioids routinely for migraine management (should be reserved for when other medications cannot be used) 2

The goal of migraine treatment should be to return control from the disease to the patient, reducing attack frequency, duration, and intensity to minimize disability and allow patients to continue with their lives with minimal hindrance 2.