Migraine Management
For migraine management, a comprehensive approach including both acute and preventive therapies is recommended, with NSAIDs, acetaminophen, or combination therapies as first-line for acute attacks and various preventive options for patients with frequent migraines. 1
Acute Treatment of Migraine
First-Line Options
- NSAIDs (ibuprofen, naproxen) or acetaminophen for mild to moderate attacks 1
- Aspirin-acetaminophen-caffeine combination is strongly recommended with significant improvement in pain freedom (NNT of 9) and pain relief (NNT of 4) at 2 hours 2
- Triptans (such as sumatriptan) combined with an NSAID (like naproxen) for moderate to severe attacks 1
- Sumatriptan shows significant headache response at 2 and 4 hours compared to placebo, with 50-62% of patients achieving headache response at 2 hours 3
Second-Line Options
- CGRP antagonists (gepants) such as ubrogepant and rimegepant are recommended as "weak for" options 2, 1
- Lasmiditan (ditan) has insufficient evidence for a strong recommendation 2
- Antiemetics should be added when nausea is prominent 1
Special Considerations
- During pregnancy: Acetaminophen is the safest acute option 1
- Cardiovascular risk: Avoid triptans in patients with cardiovascular risk factors due to potential for coronary artery vasospasm 4
- Medication overuse: Limit NSAIDs to ≤15 days/month and triptans to ≤10 days/month to prevent medication overuse headache 1
Preventive Treatment
Indications for Prevention
- Consider preventive therapy for patients with:
- ≥2 migraine attacks per month
- Attacks that are prolonged and disabling
- Reduced quality of life between attacks 1
First-Line Preventive Medications
- Beta-blockers: Propranolol (80-240 mg/day), timolol (20-30 mg/day) 1
- Tricyclic antidepressants: Amitriptyline (30-150 mg/day) 1
- Anticonvulsants: Topiramate (100 mg/day), divalproex sodium (500-1500 mg/day) 1
- CGRP pathway monoclonal antibodies: Erenumab is FDA-approved for migraine prevention in adults 5, 6
Other Preventive Options
- Angiotensin receptor blockers: Candesartan has evidence supporting its use 1, 7
- Botulinum toxin: OnabotulinumtoxinA for chronic migraine 6
- Nutraceuticals:
Non-Pharmacological Approaches
Behavioral Therapies
- Cognitive behavioral therapy has proven efficacy 1
- Relaxation techniques and biofeedback are effective preventive strategies 1, 6
Lifestyle Modifications
- Regular sleep schedule
- Consistent meal times
- Adequate hydration
- Regular physical activity
- Stress management techniques
- Identification and avoidance of personal triggers 1, 8
Treatment Algorithm
For acute attacks:
- Mild to moderate: Start with NSAIDs, acetaminophen, or aspirin-acetaminophen-caffeine
- Moderate to severe: Triptan (with or without NSAID)
- If inadequate response: Consider gepants or add antiemetics for nausea
For prevention (if ≥2 attacks/month or significant disability):
- First trial: Beta-blocker (propranolol/timolol) OR topiramate
- Second trial: Amitriptyline OR divalproex sodium
- Third trial: CGRP monoclonal antibody OR candesartan
- Consider nutraceuticals as adjuncts at any stage
For all patients:
- Implement lifestyle modifications
- Consider behavioral therapies
- Maintain headache diary to track frequency, triggers, and treatment response
Common Pitfalls to Avoid
- Medication overuse: Can lead to chronic daily headache; limit acute medications to prevent this 1
- Misdiagnosis: Only 20% of chronic migraine patients are correctly diagnosed 1
- Inadequate trial period: Allow 6-8 weeks at therapeutic dose to assess preventive effectiveness 1
- Ignoring red flags: Always evaluate for secondary causes when appropriate 1
- Vascular contraindications: Be cautious with triptans in patients with cardiovascular disease 4
By following this evidence-based approach to migraine management, clinicians can effectively reduce the frequency and severity of migraine attacks while improving patients' quality of life.