What is the typical care plan for managing migraines?

Comprehensive Migraine Management Care Plan

The optimal care plan for migraine management includes both pharmacological and non-pharmacological approaches, with NSAIDs as first-line treatment for acute attacks and preventive therapy for patients with frequent or disabling migraines. 1

Assessment and Monitoring

• Use a headache diary to track:

  • Frequency, severity, and duration of attacks
  • Associated symptoms
  • Triggers (alcohol, caffeine, foods containing tyramine/nitrates, stress, fatigue, perfumes, flickering lights)
  • Medication use and response 2, 1

• Evaluate for "red flags" that suggest secondary causes:

  • 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 examination
  • Headache during sexual activity 1

Acute Treatment Strategy

First-line (Mild to Moderate Migraines)

• NSAIDs with strongest evidence: 2, 1, 3
  • Ibuprofen
  • Naproxen sodium
  • Aspirin
  • Acetaminophen-aspirin-caffeine combination

Second-line (Moderate to Severe Migraines)

• Triptans (for patients whose migraines don't respond to NSAIDs): 2, 1
  • Sumatriptan
  • Rizatriptan
  • Eletriptan
  • Zolmitriptan
  • Almotriptan
  • Frovatriptan
  • Naratriptan

Third-line Options

• CGRP antagonists (gepants) such as rimegepant or ubrogepant 1
• Ditans such as lasmiditan (note: no driving for 8 hours after intake) 1
• Dihydroergotamine (DHE) 3

Important Considerations for Acute Treatment

• Limit acute medication use to prevent medication overuse headache:
  • NSAIDs ≤15 days/month
  • Triptans ≤10 days/month 1
• Consider triptan contraindications: 4
  • Coronary artery disease
  • Prinzmetal's variant angina
  • Wolff-Parkinson-White syndrome
  • History of stroke or TIA
  • Uncontrolled hypertension
  • Concurrent use of MAO inhibitors
• Monitor for serotonin syndrome when combining triptans with SSRIs, SNRIs, or TCAs 4

Preventive Treatment

Consider preventive therapy when: 1

• Migraines occur ≥2 times per month
• Attacks are prolonged and disabling
• Quality of life is reduced between attacks

First-line Preventive Medications

Medication	Dosage
Propranolol	80-240 mg/day
Timolol	20-30 mg/day
Amitriptyline	30-150 mg/day
Divalproex sodium	500-1500 mg/day
Sodium valproate	800-1500 mg/day
Topiramate	100 mg/day

Second-line Preventive Options

• CGRP monoclonal antibodies: 1
  • Erenumab
  • Fremanezumab
  • Galcanezumab

Non-pharmacological Approaches

• Lifestyle modifications: 1

  • Regular sleep schedule
  • Consistent meal times
  • Adequate hydration
  • Regular physical exercise (40 minutes, three times weekly)
  • Stress management techniques

• Complementary approaches: 1

  • Cognitive behavioral therapy
  • Relaxation techniques (abdominal breathing, progressive muscle relaxation)
  • Magnesium supplements (400-600mg daily)
  • Riboflavin supplements (400mg daily)
  • Coenzyme Q10 supplements

Special Populations

• Pregnancy:

  • Acetaminophen is safest acute option 1
  • Avoid valproate derivatives in women of childbearing potential 1

• Patients with cardiovascular risk factors:

  • Use caution with triptans 1
  • Consider NSAIDs as alternative

Common Pitfalls to Avoid

• Medication overuse headache:

  • Limit acute treatments to no more than twice a week 2
  • Consider preventive therapy if medication overuse is suspected

• Serotonin syndrome:

  • Monitor for mental status changes, autonomic instability, neuromuscular abnormalities when combining serotonergic medications 4

• Inadequate trial of preventive medications:

  • Allow 6-8 weeks at therapeutic dose to assess effectiveness 1
  • Target 50% reduction in attack frequency

• Missing secondary headache disorders:

  • Always evaluate for red flags suggesting other diagnoses 1