What are the clinical practice guidelines for managing migraine headaches?

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Clinical Practice Guidelines for Managing Migraine Headaches

The 2023 VA/DoD Clinical Practice Guidelines recommend a structured approach to migraine management that includes aspirin-acetaminophen-caffeine as first-line abortive therapy, CGRP inhibitors for prevention, and avoidance of opioids for routine treatment. 1

Abortive (Acute) Therapy Recommendations

First-Line Medications

  • Aspirin-acetaminophen-caffeine combination has a strong recommendation with statistically significant improvement in critical outcomes (NNT of 9 for pain freedom at 2 hours and 4 for pain relief at 2 hours) 1
  • Triptans remain a cornerstone of acute migraine treatment with established efficacy 1
  • Ubrogepant and rimegepant (CGRP antagonists/gepants) have a weak recommendation for acute treatment with moderate clinical effects (NNT of 13 for pain freedom at 2 hours) 1

Second-Line/Adjunctive Options

  • Greater occipital nerve blockade received a weak recommendation for acute migraine treatment based on limited evidence showing pain reduction versus placebo 1
  • Lasmiditan (ditan class) has a "neither for nor against" recommendation due to its adverse effect profile (driving restrictions) despite showing benefits for pain relief 1

Cautions

  • Avoid opioids for routine migraine treatment due to risk of medication overuse headache and other adverse effects 1
  • Monitor for medication overuse headache in patients with risk factors including:
    • Headache frequency ≥7 days/month
    • Frequent use of anxiolytics, analgesics, or sedative hypnotics
    • History of anxiety or depression 1

Preventive Therapy Recommendations

First-Line Medications

  • CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) have a strong recommendation for prevention of both episodic and chronic migraine 1
  • Angiotensin receptor blockers (candesartan, telmisartan) have a strong recommendation for episodic migraine prevention 1
  • ACE inhibitors (lisinopril) have a weak recommendation for episodic migraine prevention 1

Second-Line Medications

  • Topiramate has a weak recommendation for prevention of both episodic and chronic migraine 1
  • Propranolol and valproate have weak recommendations for migraine prevention 1
  • Intravenous eptinezumab (CGRP monoclonal antibody) has a weak recommendation for prevention of episodic or chronic migraine 1
  • Oral magnesium has a weak recommendation for migraine prevention 1

Non-Pharmacologic Approaches

  • Aerobic exercise or progressive strength training has a weak recommendation for prevention of both migraine and tension-type headache (typically 2-3 times weekly for 30-60 minutes) 1
  • Physical therapy delivered by a physical therapist has shown benefit for reducing headache frequency and intensity 1
  • Neuromodulation devices have insufficient evidence to recommend for or against their use in migraine treatment or prevention 1

Special Considerations

Comparative Effectiveness

  • There is insufficient evidence to recommend any specific medication over another for either acute treatment or prevention of migraine 1
  • No specific combination therapy has proven superiority for migraine prevention 1

Chronic Migraine

  • OnabotulinumtoxinA is recommended for prevention of chronic migraine (but not episodic migraine) 1
  • Preventive therapy should be initiated when patients have 4 or more migraine days per month or 2+ migraine days with significant disability despite appropriate acute therapy 1

Eliminated Recommendations

  • Previous recommendations regarding dietary trigger avoidance and elimination diets based on IgG antibody testing have been eliminated from the 2023 guidelines due to insufficient evidence 1

Implementation Pitfalls

  • Failure to distinguish between episodic migraine (<15 headache days/month) and chronic migraine (≥15 headache days/month with migraine features on ≥8 days) may lead to inappropriate treatment selection 1
  • Underdiagnosis and undertreatment of migraine remain common despite availability of effective therapies 2, 3
  • Early treatment of acute attacks is essential for optimal efficacy of abortive medications 4
  • Medication overuse can lead to progression from episodic to chronic migraine and should be carefully monitored 5

By following these evidence-based guidelines and selecting appropriate acute and preventive therapies based on migraine frequency, severity, and individual patient factors, clinicians can effectively reduce migraine burden and improve quality of life for patients with migraine headaches.

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Research

Migraine Headache Prophylaxis.

American family physician, 2019

3
Research

Treatment of migraine headaches.

Mayo Clinic proceedings, 1999

4
Research

Acute Migraine Treatment.

Continuum (Minneapolis, Minn.), 2015

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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