What is the appropriate workup and treatment for a patient presenting with migraine symptoms?

Migraine Workup and Treatment Protocol

The appropriate workup for migraine should focus on ruling out secondary causes through careful history taking and examination, while treatment should include both acute and preventive strategies based on headache frequency and severity, with NSAIDs and triptans as first-line acute treatments and topiramate or onabotulinumtoxinA as evidence-based preventive options. 1

Diagnostic Workup

Initial Assessment

• Evaluate for "red flags" that suggest secondary headache:
  • Headache worsened with Valsalva maneuver
  • Headache that awakens patient from sleep
  • New-onset headache in older patients
  • Progressively worsening headache pattern
  • Neurological symptoms or abnormal neurologic examination
  • Headache during sexual activity
  • Headache with atypical features 2

Key History Elements

• Pain characteristics: location, intensity, duration, quality
• Associated symptoms: nausea, vomiting, photophobia, phonophobia
• Frequency: number of headache days per month (≥15 days/month suggests chronic migraine)
• Triggers: foods, stress, weather changes, hormonal fluctuations
• Previous treatments and responses
• Family history of headaches 2, 1

Diagnostic Tools

• Headache diary to track frequency, severity, triggers, and medication use
• Ask patients: "Do you feel like you have a headache of some type on 15 or more days per month?" 2

Neuroimaging

• Generally not warranted for patients with typical migraine features and normal neurological examination
• Consider neuroimaging for:
  • Abnormal neurological examination
  • Unusual headache features
  • New onset in older patients
  • Progressively worsening pattern 2

Treatment Approach

Acute Treatment

1. Mild to Moderate Attacks:

   • NSAIDs (ibuprofen, naproxen)
   • Acetaminophen
   • Combination of acetaminophen + NSAID 1, 3

2. Moderate to Severe Attacks:

   • Triptans (sumatriptan 50-100mg)
     • Demonstrated efficacy in 52-62% of patients at 2 hours and 65-79% at 4 hours 4
     • Contraindicated in patients with CAD, uncontrolled hypertension, or stroke/TIA history 4
   • Combination of triptan + NSAID (e.g., sumatriptan + naproxen) 1

3. For Attacks with Significant Nausea/Vomiting:

   • Non-oral triptan formulations (nasal spray, injection)
   • Add antiemetic 1

4. Newer Options (Second-line):

   • CGRP antagonists (rimegepant, ubrogepant, zavegepant) 1, 5

Key Principles for Acute Treatment

• Begin treatment as early as possible after migraine onset
• Limit acute medications to ≤10 days/month for triptans and ≤15 days/month for NSAIDs to prevent medication overuse headache 1
• Avoid opioids and butalbital-containing medications due to risk of medication overuse 1, 3

Preventive Treatment

Indications for Prevention

• Headaches occurring ≥2 times per month
• Attacks that are prolonged and disabling
• Poor response to acute treatments
• Reduced quality of life between attacks 1

First-Line Preventive Options

1. For Episodic Migraine:

   • Propranolol (80-240 mg/day)
   • Topiramate (100 mg/day)
   • Amitriptyline (30-150 mg/day)
   • Divalproex sodium (500-1500 mg/day) 1

2. For Chronic Migraine:

   • OnabotulinumtoxinA (Botox) - only FDA-approved treatment specifically for chronic migraine 2, 1
   • Topiramate - demonstrated efficacy in randomized controlled trials 2

Second-Line Options

• Candesartan (8-32 mg daily)
• Venlafaxine (75-150 mg daily)
• Flunarizine (calcium channel blocker) 1

Lifestyle and Non-Pharmacological Approaches

• Maintain regular sleep schedule
• Stay well hydrated
• Identify and avoid personal triggers using a headache diary
• Regular aerobic exercise
• Stress management techniques
• Consider supplements: magnesium (400-600 mg daily), riboflavin (400 mg daily), coenzyme Q10 1

Special Considerations

Medication Overuse

• Frequent use of acute medications (>10 days/month for triptans, >15 days/month for NSAIDs) can lead to medication overuse headache
• May require detoxification and withdrawal of overused medications 4

Pregnancy and Lactation

• Acetaminophen is the safest acute option during pregnancy
• 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

Comorbidities

• Consider comorbid conditions when selecting medications
• Some preventive medications may affect glycemic control in diabetes
• Obesity is a risk factor for migraine chronification; topiramate may assist with weight loss 1

Treatment Evaluation

• Use a headache diary to track frequency and response
• Evaluate response after 2-3 months of preventive treatment
• Target goal for preventive treatment is a 50% reduction in attack frequency
• If inadequate response to first preventive medication after 6-8 weeks, switch to another first-line agent 1