What are the guidelines for migraine management?

Guidelines for Migraine Management

For effective migraine management, NSAIDs should be used as first-line treatment for most patients with migraine, followed by triptans as second-line therapy when NSAIDs fail, while preventive therapy should be considered for patients with frequent attacks or medication overuse risk. 1

Diagnosis and Assessment

• Suspect migraine with:

  • Recurrent moderate to severe headaches
  • Visual aura
  • Family history
  • Onset around puberty 2

• Track migraine characteristics using a headache diary:

  • Severity, frequency, and duration of attacks
  • Degree of disability
  • Response to treatment
  • Medication side effects
  • Potential triggers (alcohol, caffeine, certain foods, stress, etc.) 2, 1

Acute Treatment Algorithm

Step 1: First-Line Treatment (Mild to Moderate Attacks)

• NSAIDs with strongest evidence:
  • Ibuprofen (400-600mg)
  • Naproxen sodium (500-550mg)
  • Aspirin
  • Acetaminophen-aspirin-caffeine combination 2, 1

Important: Acetaminophen alone is ineffective for migraine treatment 2, 1

Step 2: Second-Line Treatment (Moderate to Severe Attacks or NSAID Failure)

• Triptans:
  • Sumatriptan: 50mg orally (up to 100mg if needed); 6mg subcutaneously for severe attacks
  • Rizatriptan: 10mg orally
  • Other options: naratriptan, zolmitriptan, almotriptan 1, 3

Dosing caution: Maximum daily dose of sumatriptan is 200mg in a 24-hour period, with at least 2 hours between doses 3

Step 3: Refractory Attacks

• Combination of triptan plus NSAID
• Dihydroergotamine (DHE) intranasal
• Antiemetics (even if vomiting is not present)
• Rescue medications: butorphanol nasal spray or opioids 1

Preventive Treatment

When to Consider Prevention

• ≥15 headache days per month (chronic migraine)
• Medication overuse risk (acute treatments >2 days/week)
• Significant disability despite acute treatment 2

Preventive Options (by Evidence Level)

1. Strong Evidence:

   • CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab)
   • Beta blockers (propranolol)
   • Topiramate
   • Tricyclic antidepressants (amitriptyline) 1

2. For Chronic Migraine:

   • OnabotulinumtoxinA (Botox) injections 4

Special Populations

Children and Adolescents

• Ibuprofen is first-line treatment
• Rizatriptan ODT, zolmitriptan nasal, or sumatriptan nasal for acute treatment
• Propranolol, amitriptyline with cognitive behavioral therapy, or topiramate for prevention 1

Pregnancy and Breastfeeding

• Acetaminophen is safest for acute treatment
• Avoid preventive medications when possible 2, 1

Non-Pharmacological Approaches

• Regular aerobic exercise and strength training
• Consistent sleep schedule
• Adequate hydration
• Relaxation techniques and mindfulness
• Biofeedback combined with relaxation training
• Cognitive-behavioral therapy 1

Important Cautions

Medication Overuse Risk

• Limit acute treatments to prevent medication overuse headache:
  • Triptans: No more than 9 days/month
  • NSAIDs: No more than 15 days/month
  • OTC medications: No more than 14 days/month 1

Contraindications

• Triptans are contraindicated in:

  • Uncontrolled hypertension
  • Cardiovascular disease
  • Basilar or hemiplegic migraine 2, 1

• OnabotulinumtoxinA risks:

  • Problems with swallowing, speaking, or breathing
  • Spread of toxin effects beyond injection site 4

Long-term Management

• Regularly evaluate treatment effectiveness using headache calendars
• Reassess diagnosis, treatment strategy, and adherence if outcomes are suboptimal
• Manage comorbidities to improve overall outcome 2, 1

By following these evidence-based guidelines, most migraine patients can achieve significant improvement in symptoms and quality of life.