What are the best treatment options for a patient with a significant history of migraines?

Treatment Options for Patients with Significant History of Migraines

For patients with a significant history of migraines, the most effective treatment approach is a stepped care strategy starting with NSAIDs for mild to moderate attacks, triptans for moderate to severe attacks, and reserving gepants or ditans for those who fail first-line options, while implementing preventive therapy for patients with frequent attacks. 1

Acute Treatment Algorithm

First-Line Options

• Mild to Moderate Attacks:

  • NSAIDs (ibuprofen, aspirin, naproxen, diclofenac) 1
  • Acetaminophen (less effective alone but useful in combination) 1
  • Combination analgesics (acetaminophen + aspirin + caffeine) 1, 2

• Moderate to Severe Attacks:

  • Triptans (sumatriptan, rizatriptan, etc.) 1, 2
  • Most effective approach: triptan + NSAID combination taken early in the attack 1
  • For patients with severe nausea/vomiting: non-oral triptans and antiemetics 1

Second-Line Options

• CGRP antagonists (gepants) for patients who don't respond to or cannot tolerate triptans + NSAIDs 1
• Dihydroergotamine (DHE) for triptan non-responders 1
• Antiemetics (for associated symptoms or as adjunctive therapy) 2

Third-Line Options

• Ditan (lasmiditan) - only after failure of all other treatments 1
• Ubrogepant (50-100 mg at onset, maximum 200 mg/24 hours) 1

Preventive Treatment

Indications for Preventive Therapy

• ≥4 headaches per month
• ≥8 headache days per month
• Debilitating attacks despite acute treatment
• Medication overuse headache
• Significant migraine-related disability 3

First-Line Preventive Medications

• Beta-blockers:
  • Propranolol (80-240 mg/day)
  • Timolol (20-30 mg/day) 1, 3
• Anticonvulsants:
  • Topiramate (100 mg/day)
  • Divalproex sodium (500-1500 mg/day) 1, 3
• Antidepressants:
  • Amitriptyline (30-150 mg/day) 1, 3, 4

Newer Preventive Options

• CGRP monoclonal antibodies (e.g., erenumab) 5, 4
  • Effective for both episodic and chronic migraine
  • Administered monthly by subcutaneous injection
  • Demonstrated significant reduction in monthly migraine days 5

Complementary Preventive Treatments

• Magnesium citrate 1, 4
• Riboflavin (vitamin B2) 1, 4
• Coenzyme Q10 4
• Petasites and feverfew 3

Non-Pharmacologic Approaches

Behavioral Interventions

• Relaxation training
• Thermal biofeedback combined with relaxation
• Cognitive behavioral therapy 3, 4

Lifestyle Modifications

• Regular sleep schedule
• Consistent meal times
• Adequate hydration
• Regular exercise
• Stress management techniques 1
• Identification and avoidance of personal triggers using a headache diary 1, 6

Important Cautions

Medication Overuse Prevention

• Limit NSAIDs to ≤15 days/month
• Limit triptans to ≤10 days/month 1
• Monitor for medication overuse headache (≥15 headache days/month with regular overuse of acute medications) 7

Contraindications

• Avoid triptans in patients with cardiovascular risk factors (coronary artery disease, uncontrolled hypertension, history of stroke) 1
• Avoid valproate during pregnancy due to teratogenicity 1
• Avoid opioids and butalbital-containing medications due to risk of dependence and medication overuse headache 1, 2

Special Considerations

Chronic Migraine

• Defined as headache on ≥15 days/month for >3 months, with migraine features on ≥8 days/month 7
• Consider onabotulinumtoxinA as a preventive option 4
• More aggressive preventive approach often needed 7

Migraine with Aura

• Requires special consideration for contraceptive choices and cardiovascular risk assessment
• Same acute treatment approach as migraine without aura 7

By following this structured approach to migraine management, focusing on appropriate acute treatment while implementing preventive strategies for frequent attacks, most patients with a significant history of migraines can achieve substantial improvement in their condition and quality of life.