What are the management options for migraines?

Migraine Management Options

For migraine management, use NSAIDs or triptans for acute attacks based on severity, and consider preventive therapy with beta-blockers, antidepressants, or anticonvulsants for frequent migraines, while implementing lifestyle modifications to avoid triggers. 1

Acute Treatment Strategy

Mild to Moderate Migraine Attacks

• First-line options:
  • Ibuprofen 400-800 mg every 6 hours (maximum 2.4g/day) 1
  • Aspirin 650-1000 mg every 4-6 hours (maximum 4g/day) 1
  • Combination analgesics containing caffeine 2, 1
  • Isometheptene combinations (e.g., Midrin) 2

Moderate to Severe Migraine Attacks

• First-line options:
  • Triptans:
    • Zolmitriptan 2.5-5 mg every 2 hours (maximum 10 mg/24 hours) 1
    • Sumatriptan (use with caution in patients with cardiovascular risk factors) 3
    • Rizatriptan (contraindicated in patients with CAD or Prinzmetal's angina) 4
  • Triptan + NSAID combination (high-strength evidence) 1
  • CGRP antagonists (gepants): rimegepant, ubrogepant, zavegepant 1

For Migraines with Nausea/Vomiting

• Use non-oral routes of administration 2
• Consider antiemetics like metoclopramide (Reglan) or prochlorperazine (Compazine) as adjunctive therapy 2

Preventive Treatment

Indications for Preventive Therapy

• Frequent migraine attacks (≥4 per month)
• Significant disability despite acute treatment
• Contraindication to or failure of acute treatments
• Risk of medication overuse headache 1, 5

First-line Preventive Options

• Beta-blockers:

  • Propranolol 80-240 mg/day
  • Timolol 20-30 mg/day
  • Avoid in patients with asthma, heart failure, Raynaud's disease, AV block, or depression 1

• Antidepressants:

  • Amitriptyline 30-150 mg/day 1

• Anticonvulsants:

  • Topiramate 100 mg/day
  • Divalproex sodium 500-1500 mg/day
  • Note: Valproate is contraindicated during pregnancy 1

• Alternative options:

  • Candesartan 16-32 mg/day 1

Non-Pharmacological Approaches

Lifestyle Modifications

• Regular sleep schedule
• Consistent meal times
• Adequate hydration
• Regular exercise
• Stress management techniques 1

Complementary Therapies

• Relaxation training
• Thermal biofeedback combined with relaxation training
• Electromyographic biofeedback
• Cognitive-behavioral therapy 1
• Supplements: magnesium, riboflavin, coenzyme Q10 1, 5

Important Cautions and Monitoring

Medication Overuse Headache

• Limit acute medications to prevent medication overuse headache:
  • NSAIDs ≤15 days/month
  • Triptans ≤10 days/month 1
  • Opioids should be avoided for chronic daily headaches 2

Triptan Contraindications

• Coronary artery disease
• Prinzmetal's variant angina
• Uncontrolled hypertension
• History of stroke or TIA
• Wolff-Parkinson-White syndrome 3, 4

Serotonin Syndrome Risk

• Use caution when combining triptans with SSRIs, SNRIs, TCAs, or MAO inhibitors 3, 4

Preventive Treatment Monitoring

• Evaluate after 4-6 weeks of treatment
• Continue effective prophylactic treatment for at least 3-6 months
• Taper gradually over several weeks when discontinuing 1

Special Populations

Pregnancy

• Paracetamol (acetaminophen) is first-line for migraine during pregnancy 1
• Avoid valproate due to teratogenicity 1

Breastfeeding

• Paracetamol, ibuprofen, and sumatriptan are considered safe options 1

By following this structured approach to migraine management, focusing on appropriate acute treatment based on severity and implementing preventive strategies for frequent migraines, patients can experience significant improvement in their quality of life and reduced disability from migraine attacks.